New Patient Form - Pine Belt Dermatology & Skin Cancer Center

Insurance Information
Primary Insurance*
Policy Holder's Name *

First NameLast Name
Policy Holder's DOB*

MonthDayYear
Date
ID# *
Group #*
Relationship to Policy Holder*
Example: Self, parent
Prescription Coverage*
Do you have secondary insurance?*

YesNo
Secondary Insurance*
Policy Holder's Name *

First NameLast Name
Policy Holder's DOB*

MonthDayYear
Date
ID# *
Group #*
Relationship to Policy Holder*
Example: Self, parent
Insurance Card- Front

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Insurance Card- Back

Cancelof
Photo ID

Cancelof
By signing below, I acknowledge and consent that all information provided is true and correct.
Patient Signature *

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Guardian Signature *

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DateTime

Financial & Office Policies
We would like to thank you for choosing Pine Belt Dermatology & Skin Cancer Center for all your dermatological needs. Pine Belt Dermatology & Skin Center is committed to providing you with the best possible medical care. The following outlines your financial responsibilities related to payment for professional services.
No Show Fee:
Please Kindly give a 48-hour notice if you are unable to keep your follow up appointment. Our office reserves the right to charge your account $25.00 in the event you do not show for your scheduled appointment.
No Show Surgical Appointment Fee:
Please Kindly give a 48-hour notice if you are unable to keep a surgical appointment. Please note there will be a fee in the amount of $200.00 added to your account in the event you do not show for your surgical appointment.
For Our Patients with Medical Insurance Benefits:
We participate in most major health plans. We have contracts with many HMO's, PPO's Insurance companies and government agencies including Medicare and Medicaid. Our business office will assist you in any way reasonable we can to get your claims paid. It is the patient's responsibility to provide all necessary information before leaving the office. If you have a secondary insurance, we will automatically file a claim with them as soon as the primary carrier has paid.
Co- Payments:
Your insurance company required us to collect co- payments at the time of service. Waiver of co-payments constitutes fraud under state and federal law. For your convenience, we accept cash, checks or the following credit cards: Visa, MasterCard, Discover, American Express and Care Credit.
Additionally, you may have coinsurance and/ or deductibles, or other financial responsibility required by your insurance carrier. Any outstanding balance on your account, after adjusting for all of your insurance responsibilities, will be billed to you.
Surgery sliding scale for those patient's needing financial Assistance:
In the event you need assistance paying for a surgery that has been discussed with your provider, our office has to set up guidelines in order to be able to legally assist our patients who may not have the means to cover their services entirely. Please see a staff member to discuss this matter privately.
Non- Covered and Out of Network Services:
Medical services that are considered by your insurance company to be non- covered, out of network, or not medically necessary will be your responsibility.
For Our Patients with no Medical Insurance:
If you do not have group or individual medical insurance, we do offer a self- pay rate. A minimum of $50.00 will be required on office visits and $100.00 on surgical procedures.
Payment Plan:
Please let us know If you are having difficulty paying your account. We are more than willing to make arrangements that will fit your budget.
Delinquent Balance Appointment:
If you have a balance more than 120 days old, you will be required to pay an additional amount towards the outstanding balance and a payment plan must be set up.
Collection Agency Fees:
All patient's balances that require placement with an outside collection agency will be assessed a fee of 35% for the total balance owed on the account.
Cosmetic Services:
Services for cosmetic procedures or any service deem non- medically necessary by the provider, are required to be paid in full at the time of service. There is a $65.00 no show fee for missed cosmetic appointments.
Waiver of Patient Responsibility:
It is the policy of the practice to treat all patients in an equitable fashion related to patient balances. The practice will not waive, fail to collect or discount co-payments, co -insurance, deductibles or other patient responsibility in accordance with state and federal law, as well as participating agreements with payers. Full or partial financial responsibility may only be waived in accordance with the practice's Charity/Free Care Policy.
Updated 10/25/2019 jlm
Photography:
Our Providers require the use of photography in your medical chart. In short, it is another way to identify the patient and the medical record. Our office does not sell or distribute your personal information including pictures to any outside source. The only exception to this is for payment of your medical claim, your consent and request or required by law enforcement.

HIPAA Consent:
It is the practice of the office not to release your medical information to anyone without your written authorization. If you would like our office to discuss your confidential medical information with someone other than you such as, your primary care physician, spouse or family member, please list the person(s) and their relationship to you.

We are required by law to provide you with a notice that explains our privacy practices with regards to your medical information and how we may use and disclose your protected health information, payment, for healthcare operations, as well as for other purposes that are permitted or required by law. You have certain rights regarding the privacy of your protected health information as we describe them in our HIPAA policy. Please see the staff for a full copy of our HIPAA policy.
No, I would not like to disclose any of my health information with anyone.Yes, I would like to disclose my health information with the following.
Printed Name of Authorized Person(s)*

First NameLast Name
Authorized Person(s) Phone Number*
Please enter a valid phone number.
Printed Name of Authorized Person(s)

First NameLast Name
Authorized Person(s) Phone Number
Please enter a valid phone number.
How do you want to be contacted?*

TextEmailPhone
Is this patient under 18?

YesNo
Date of Consent*

MonthDayYear
Date
In the event I am unable to attend my child/children's appointments, I hereby authorize the following individual(s) to bring them in my absence:
Name*

First NameLast Name
Relationship to Patient*
Name

First NameLast Name
Relationship to Patient
I also authorize Pine Belt Dermatology and its providers to render medically necessary treatment to my child/children in my absence:
Name of Child*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Parent/Legal Guardian Signature:*

Clear
Printed Name & Relationship:*
Date of Consent:*

MonthDayYear
Date
Your Name*

First NameLast Name
Patient Signature*

Clear
Guardian Signature (If patient is under 18, the parent or legal guardian must be present for the initial visit.)*

Clear
Patient DOB*

MonthDayYear
Date
Guardian DOB*

MonthDayYear
Date
DateTime
Should be Empty:

	Yes	No
Anxiety
Arthritis
Asthma
Atrial fibrillation
Bone Marrow Translation
Enlarged Prostate
Breast Cancer
Colon Cancer
COPD
Coronary Artery Disease
Depression
Diabetes
Kidney Disease
GERD/Heartburn
Hearing Loss
Hepatitis
High Blood pressure
HIV/AIDS
High Cholesterol
Hyperthyroidism
Hypothyroidism
Leukemia
Lung Cancer
Lymphoma
Prostate Cancer
Radiation Treatment
Seizures
Stroke
Eczema
Melanoma
Precancerous moles
Psoriasis
Skin Cancer
None of these

	Name	Times/Day	Dose	RX Number
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
Medication #10

	Yes	No
Problems with healing
Problems with scaring Sore Throat
Immunosuppression
Problems bleeding
Chest pain
Fever or chills
Night sweating
Muscle weakness
Neck Stiffness
Headaches
Bloody Stool
Bloody Urine
Abdominal Pain
Blurry vision
Unintentional Weight Loss
Shortness of breath
Wheezing
Rash
Joint aches
Pregnant or trying to become?
Breastfeeding
Seizures
Cough
None of these

Pine Belt Dermatology & Skin Cancer Center

Insurance Information

Medical History

Financial & Office Policies